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Pulaskicounty.org

Prescription
Program
Drug List/Formulary — To be used by
members who have a tiered drug plan.

Anthem Blue Cross and Blue Shield
prescription drug benefits include
medications available on the Anthem
Drug List/Formulary. Our prescription
drug benefits can offer potential
savings when your physician prescribes
medications on the drug list/formulary.

For Kentucky Residents Only:
In selecting medications for the prescription drug formulary, the therapeutic
efficacy and cost effectiveness are addressed for each category. All
therapeutic categories are represented on the formulary by at least one
medication. When a closed formulary is in effect, only medications that are
included on the formulary are a covered service. In certain clinical situations, a
member may require use of a non-formulary product. Anthem has criteria that
permits a member to obtain a non-formulary medication in a closed formulary
plan. If specific criteria are met, a member can receive a non-formulary drug
for a formulary copay. The criteria preserves the clinical integrity of the drug
formulary and provides a process by which deviations from the formulary may
be allowed. An appeals process is in place for any medications that do not meet
the criteria.
For more information, please visit anthem.com.
If you have additional questions about your prescription
benefits please call the Member Services number on your
ID card

Speech and hearing impaired (TDD/TTY users) should call
800-221-6915, Monday – Friday, 8:30 a.m. – 5:00 p.m., ET
For the most current version of this prescription drug
list, please visit anthem.com
Bring a copy of this drug list/formulary to your next doctor’s
visit to assist in selecting the lowest cost medications
Life and Disability products are underwritten by Anthem Life Insurance Company. In Colorado: Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. In Indiana: Anthem Blue Cross and Blue Shield is a trade name of Anthem Insurance Companies, Inc. In Kentucky: Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Kentucky, Inc. In Missouri: Anthem Blue Cross and Blue Shield is the trade name RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC) and HMO Missouri, Inc. use to do business in most of Missouri. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. In Ohio: Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. In Wisconsin: Blue Cross Blue Shield of Wisconsin (“BCBSWi”) underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (“Compcare”) underwrites or administers the HMO policies; and Compcare and BCBSWi collectively underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® Blue Cross and Blue Shield are registered marks of the Blue Cross and Blue Shield Association.
Tier 1 – Lowest copayment – Drugs offering the greatest value within a therapeutic
class. Some of these are generic equivalents of brand name drugs.
Tier 2 – Medium copayment – Drugs on this tier are generally the more affordable
brand-name drugs. Other drugs are on this tier because they are “preferred”
within their therapeutic classes, based on clinical effectiveness and value
Tier 3 – Highest copayment – These are higher cost brand-name drugs. Some Tier 3
drugs may have generics or equivalents in Tier 1. In addition, some drugs on this tier may
have been evaluated to be less cost-effective than equivalent drugs on lower tiers.
Tier 4 – Many drugs on this tier are “specialty” drugs used to treat complex,
chronic conditions and may require special handling and/or management. For
members who do not have a Tier 4 plan, these drugs are found under Tier 1, 2 or 3.
Azathioprine
Cephalexin
Azithromycin QL
Chloral hydrate
Acarbose
Bacitracin zinc/polymyxin B Chlordiazepoxide
Acebutolol
Bacitracin/polymyxin/
Chlorhexidine gluconate
Acetaminophen/
neomycin-hc opth oint
Chloroquine 250mg
caffeine/butalb
Baclofen
Chlorothiazide
Acetazolamide, SR
Balsalazide
Chlorphen/pyrilamine/
Acetic acid
Belladonna/phenobarbital
phenylephrine
Acetic acid/hydrocortisone Benazepril, HCTZ
Chlorpheniramine/
Acetic acid/aluminum
Benzoyl peroxide
pseudoephedrine
Benzoyl peroxide/
Chlorpromazine tab
Acetic acid otic
erythromycin
Chlorpropamide
Acetylcysteine
Benztropine
Chlorthalidone
Acyclovir
Betamet diprop/
Chlorzoxazone
Albuterol
Cholestyramine, light
Albuterol/ipratropium
Betamethasone
Chorionic gonadotropin
dipropionate
Alendronate QL
Betamethasone valerate
Ciclopirox
Allopurinol
Betaxolol
Cimetidine
Alprazolam
Bethanechol
Ciprofloxacin QL
Amantadine
Bisoprolol
Citalopram DO, QL
Amcinonide
Bisoprolol/HCTZ
Clemastine fumarate
Amiloride
Bromocriptine
Clindamycin
Amiloride/
Budeprion XL DO, QL
Clobetasol
hydrochlorothiazide
Bumetanide
Clomiphene
Aminophylline
Bupropion
Clomipramine
Amiodarone
Buspirone
Clonazepam
Amitriptyline
Butalbital Compound
Clonidine
Amitriptyline/perphenazine
w/Codeine
Clorazepate
Amitriptyline/
Butorphanol tartrate
Clotrimazole/
chlordiazepoxide
10mg/ml N.S. QL
betamethasone
Amlodipine DO, QL
Cabergoline
Clozapine
Amlodipine/benazepril
Calcipotriene Soln.
Codeine sulfate
Amnesteem QL
Calcium Acetate
Codeine/APAP QL
Amoxapine
Captopril, HCTZ
Colchicine
Amoxicillin
Carbamazepine
Cromolyn
Amoxicillin/
Carbidopa/levodopa
Cyclobenzaprine
clavulanate QL
Carbidopa/levodopa CR
Cyclopentolate
Amphetamine
Carisoprodol
Cyproheptadine
Ampicillin
Carteolol hcl
Antipyrine/benzocaine
Cartia XT DO, QL
Dantrolene
APAP/caffeine/butalbital
Carvedilol
Desipramine
Cefaclor
Desmopressin acetate
Asa/codeine
Cefaclor ER
Desonide
Aspirin/caffeine/butalbital Cefadroxil
Desoximetasone
Atenolol
Cefdinir
Dexmethylphenidate
Atenolol/chlorthalidone
Cefpodoxime
Dextroamphetamine
Atropine sulfate
Cefprozil
Dextromethorphan/
Aviane PA
Cefuroxime QL
guaifenesin
Diazepam
Fludrocortisone
Ipratropium bromide neb
Diclofenac potassium
Flunisolide Nasal
soln/nasal spray QL
Diclofenac sodium
Iron combination capsule
Fluocinolone acetonide
Iron/intrinsic factor/B12
Diclofenac, ER
Fluocinonide
Iron/B12/folic acid
Dicloxacillin
Fluorometholone
Isometh/dichlphen/APAP
Dicyclomine
Fluorouracil
Isoniazid
Didanosine
Fluoxetine DO, QL
Isosorbide dinitrate
Diflorasone diacetate
Fluphenazine
Isosorbide mononitrate
Diflunisal
Flurazepam
Isotretinoin QL
Flurbiprofen
Itraconazole PA
Diltia XT DO, QL
Flurbiprofen sodium
Ketoconazole
Diltiazem
Flutamide
Ketoprofen, ER
Diltiazem CD DO, QL
Fluticasone Nasal
Ketorolac QL
Diltiazem CR DO, QL
Labetalol
Diltiazem SR DO, QL
Fluvoxamine DO
Lactulose
Diphenhydramine 50mg
Folic acid
Lamotrigine
Diphenoxylate/
Fosinopril DO, QL
Leflunomide
atropine sulfate
Leucovorin
Dipivefrin HCl
Fosinopril HCTZ
Leuprolide PA*
Dipyridamole
Furosemide
Levetiracetam
Disopyramide
Gabapentin
Levobunolol
Disopyramide CR 150mg
Galantamine, SR
Levonorgestrel & ethinyl
Divalproex
Ganciclovir
estradiol PA
Dorzolamide
Gemfibrozil
Levora PA
Dorzolamide/timolol
Gentamicin
Doxazosin mesylate
Glimepiride
Levorphanol tartrate
Glipizide XL
Lidocaine
Doxycycline
Glipizide/metformin
Lidocaine viscous
Doxycycline monohydrate
Glyburide
Lisinopril, HCTZ
Dronabinol
Glyburide micronized
Dyphylline
Glyburide/metformin
Loperamide
Econazole
Glycolax
Lorazepam
Enalapril, HCTZ
Granisetron QL
Lovastatin DO, QL
Ergotamine
Guaifenesin
Low-ogestrel
Ergotamine/
Guaifenesin SR
belladonna/PB
Guaifenesin/dextrometh
Loxapine
Erythromycin
Mebendazole
Guaifenesin/hydrocodone
Erythromycin base
Meclizine
Guanabenz
Erythromycin
Meclofenamate
Guanfacine
ethylsuccinate
Medroxyprogesterone
Halobetasol
Erythromycin/sulfisoxazole
Mefloquine
Haloperidol
Estradiol
Megestrol
Heparin*
Estradiol/
Meloxicam QL
norethindrone PA
Homatropine
Meperidine
Estropipate
Hydralazine
Meperidine w/promethazine
Ethambutol
Hydralazine/HCTZ
Mercaptopurine
Ethinyl estradiol/
Hydrochlorothiazide
Metaproterenol
norethindrone PA
Hydrocodone w/
Metformin
Ethinyl estradiol/ethynodiol homatropine
Metformin ER
diacetate PA
Hydrocodone/APAP QL
Meth/salicylate/atropine/
Ethosuximide
Hydrocortisone 2.5%
hyos benzoic
Etodolac
cream, ointment, lotion
Methadone
Etodolac ER
Hydrocortisone enema
Methazolamide
Etoposide
Hydromorphone
Methenamine/
Famciclovir
Hydroxychloroquine
hyosc-meth blue/sod
Famotidine
Hydroxyurea
biphos-phenyl sal
Felodopine DO, QL
Hydroxyzine HCL
Methocarbamol
Fenoprofen
Hydroxyzine pamoate
Methotrexate tablets
Fentanyl QL
Hyoscyamine
Methyclothiazide
Fexofenadine, D QL
Ibuprofen
Methyldopa
Finasteride
Imipramine
Methyldopa/HCTZ
Flecainide
Indapamide
Methylphenidate, SR
Fluconazole
Indomethacin, SR
Methylprednisolone
Metoclopramide
Oxaprozin
Prochlorperazine
Metolazone
Oxazepam
Prochlorperazine supp
Metoprolol, SR
Oxybutynin
Metoprolol/HCTZ
Oxycodone
Promethazine
Metronidazole
Oxycodone ER QL
Promethazine/codeine
Mexiletine
Oxycodone/aspirin
Promethazine/
Miconazole nitrate
Oxycodone/APAP QL
dextromethorphan
Microgestin PA
Oxytocin
Promethazine/
Midodrine
Pantoprazole ST, QL^#
phenylephrine
Minocycline
Paroxetine, SR DO, QL
Propafenone
Minoxidil
Penicillin V.K.
Propantheline
Mirtazapine
Pentamidine isethionate
Propoxyphene/APAP QL
Misoprostol
Pentazocine nx
Propranolol, LA
Moexipril, HCTZ
Pentazocine/apap
Propranolol/HCTZ
Mometasone ointment,
Pentoxifylline
Propylthiouracil
Pergolide
Pseudoephed/bromphen-
Morphine SR QL
Permethrin
DM 45-4-15
Morphine sulfate
Perphenazine
Pseudoephedrine hcl/
Multivitamins w/fluoride
Phenazopyridine
chlor-mal
Multivitamins w/folic acid
Phenobarbital
Pseudoephedrine/
Nabumetone
Phenyleph hcl/hydrocod
guaifenesin
Pseudoephedrine/
Naltrexone hcl
Phenyleph/chlorphen/
carbinoxamine
Naphazoline
Pyrazinamide
Naproxen
Phenyleph/chlorphen/
Quinapril, HCTZ
Naproxen EC
hydrocodone
Quinidine gluconate
Naproxen sodium, DS
Phenyleph-ephed-cpd
Quinidine sulfate
w/carbetapentane
Ramipril
Neomycin
Phenyleph-pyrilamine
Ranitidine
w/hydrocodone
Neomycin/dexamethasone
Ribavirin PA
Phenylephrine
Neomycin/polymixin/
Rifampin
hydrocortisone
Phenylephrine/
Risperidone
promethazine/codeine
Neomycin/polymyxin/
Ropinirole
dexamethasone
Phenytoin
Salsalate
Neomycin/polymyxin/
Phospha 250
Selegiline
bacitracin
Pilocarpine
Selenium sulfide
Neomycin/polymyxin/
Pindolol
Sertraline DO, QL
gramicidin
Piroxicam
Silver sulfadiazine
Polyethylene glycol-
Simvastatin DO, QL
Nicardipine
electrolyte solution
Sodium citrate &
Nifedipine
Polymyxin B/trimethoprim
citric acid
Nifedipine ER DO, QL
& Sod. Citrates w/citric
Sodium fluoride
Nisoldipine DO, QL
Sodium polystyrene
Nitrofurantoin
Potassium chloride
sulfonate
Nitrofurantoin mono
Potassium citrate
Sodium sulfacetamide/
Nitroglycerin
Potassium citrate-citric
Nitroglycerin ointment
Sotret QL
Nitroglycerin SR
Pramoxine/hc/
Spironolactone
Nizatidine
chloroxylenol
Spironolactone/HCTZ
Norethindrone
Pravastatin DO, QL
Stannous fluoride
Nortriptyline
Prazosin
Stavudine
Nystatin
Prednisolone
Sucralfate
Nystatin/triamcinolone
Prednisolone sodium
Sulfacet sod w/sulfur
Ocella PA
prosphate
Ofloxacin QL
Prednisone
Sulfacetamide sodium
Omeprazole 10 &
Prenatal mulitvitamins and
solution
minerals/iron/folic acid
Sulfacetamide sodium/
Omeprazole 40mg
Prenatal vitamin
prednisoloneophth sol.
Prenatal w/docusate, iron,
Sulfamethoxazole/
Ondansetron QL
folic acid
trimethoprim, DS
Orphenadrine
Primidone
Sulfasalazine, EC
Orphenadrine cpd
Probenecid
Sulfinpyrazone
Orphenadrine cpd
Probenecid/colchicine
Sulindac
Procainamide, SR
Sumatriptan QL
QuesTions anD answers
Q. What is a Drug List/Formulary?
a. The Anthem Drug List/Formulary is a list of FDA-approved brand-name
and generic medications that have been reviewed and recommended for their quality and effectiveness by the National Pharmacy and Therapeutics (P&T) Committee. The P&T Committee is an independent group of practicing doctors and pharmacists responsible for the research and decisions surrounding our drug list. This group meets regularly to review new and existing drugs and choose the top medications for our drug list—based on their safety, effectiveness and value. Drugs on the Anthem Drug List/Formulary are grouped by ‘tiers.’ A number of factors are considered when classifying drugs into tiers, including, but not limited to: the absolute cost of the drug; the cost of the drug relative to other drugs in the same therapeutic class; the availability of over-the-counter alternatives; and other clinical and cost-effectiveness factors.
Because the medications on the drug list/formulary are subject to periodic review, please ask your physician about the most current drug list additions and deletions or visit anthem.com. Brand-name: A brand-name drug is usually available from only one
manufacturer and may have patent protection. Generic: A generic drug is required by the FDA to have the same active
ingredients as its brand-name counterpart, but is normally only available after the patent protection expires on a brand-name drug. Although it may look different, a generic drug works the same as its brand-name counterpart. You can save money by using generic medications. Q. What if my physician or I choose a brand-name drug when a
generic equivalent is available?
a. In most cases, you would be responsible for the appropriate tier
copay. This copay may include an additional charge that represents the cost difference between the brand-name medication and the generic equivalent.
Q. What are ‘clinically equivalent’ medications? How does this affect
my drug coverage?
a. The P&T Committee reviews the most current research available to
determine if multiple drugs used to treat a disease/condition produce the same clinical effect. When this is the case, the committee may recommend that we cover only the lower cost drug(s) as part of our effort to help reduce the overall cost of care. This means your specific prescription plan may not cover some drugs in classes with ‘clinically equivalent’ alternatives.
Q. What if my medication is not on the drug list/formulary?
a. An open drug list allows members and their physicians to choose from
a wide variety of prescription medications. Please talk with your doctor about prescribing a Tier 1 or Tier 2 medication. If a Tier 3 medication is selected, you will be responsible for the applicable Tier 3 copayment.
You or your physician may submit a request to add a drug to the drug list/formulary either in writing or on our web site. Requests are taken into consideration by the P&T Committee during the drug list/formulary review process. Inclusion of a medication on the drug list/formulary is not a guarantee of coverage. Some drugs, such as those used for cosmetic purposes, may be excluded from your benefits. Please refer to your Certificate or Evidence of Coverage for coverage limitations and exclusions.
Tamoxifen
Temazepam
Effexor XR DO, QL
Terazosin
Alphagan P
Elidel ST
Terbinafine PA
Altace 2.5, 5 & 10mg
Terbutaline
Androderm PA, QL
Terconazole
Androgel PA, QL
Entocort EC
Theophylline
Antabuse
Epipen, JR.
Theophylline SR
Theophylline syrup
Estraderm
Thioridazine
Arimidex
Thiothixene
Armour Thyroid
Ethmozine
Ticlopidine
Aromasin
Tizanidine
Asmanex QL
Exelderm
Tobramycin*
Tolmetin
Atrovent HFA QL
Exforge DO, QL
Torsemide
Avandamet QL
Fansidar
Tramadol QL
Avandaryl QL
FazaClo ODT
Tramadol/APAP QL
Avandia QL
Felbatol
Trandolapril
Tranylcypromine
Trazodone
Azmacort QL
Tretinoin PA
Flovent, HFA QL
Triamcinolone acetonide
Beptoptic S
Fluoroplex
Triamterene/HCTZ
FML Forte
Triazolam
Blephamide
Trifluoperazine
Byetta ST, QL
Foradil QL
Trifluridine
Calciferol drops
Fortovase
Trihexyphenidyl
Capitrol
Fosamax solution QL
Trimethobenzamide
Carbatrol
Fosamax Plus D QL
Trimethoprim
Fosrenol
Tri-nessa PA
Furadantin
Triple sulfa
Cellcept
Furoxone
Triple vitamins w/fluoride
Cenestin
Trivora PA
Ciprodex
Gabitril
Tropicamide
Climara Pro
Gantrisin
Trypsin/balsam peru/
Clozaril
castor oil
Combivent QL
Gleevec PA
Ursodiol
Combivir
Glucagon
Valproic acid
Venlafaxine
Concerta
Verapamil, SR
Humibid Cap Sprinkle
Warfarin
Humulin N, R, 50/50, 70/30
Yohimbine
Coumadin
Hyzaar DO, QL
Zaleplon ST, QL
Cozaar QL
Imitrex QL
Zolpidem QL
Intal Inh.
Zonisamide
Crixivan
Invirase
Cuprimine
Iressa PA
Cymbalta DO, QL
Janumet QL
Cytadren
Januvia QL
Accu-chek Product Line QL
Daraprim
Actonel QL
Depakote, ER
Actonel with Calcium QL
Derma-Smoothe, FS
Lanoxicaps
ActoPlus Met QL
Detrol, LA
Adderall XR
Dibenzyline
Leukeran
Advair Diskus, HFA QL
Differin
Leukine PA*
Aerobid QL
Dilantin
Levaquin QL
Aerobid M QL
Diovan DO, QL
Agenerase
Diovan HCT DO, QL
Levothroid
Akne-Mycin
Dovonex cream
Lexapro DO, QL
Aldara QL
Lipitor DO, QL
Procanbid
Viramune
Loprox gel, shampoo
Lotrel (5/40 & 10/40mg)
Prometrium
Vivelle, DOT
Protopic ST
Vyvanse PA
Proventil HFA QL
Matulane
Pulmicort Respules QL
Xeloda PA
Maxalt, MLT QL
Pulmicort Turbuhaler QL
Xopenex HFA QL
Medrol 2mg, 16mg, 32mg
Rapamune
Zarontin
Mephyton
Rescriptor
Mestinon timespan
Retin-A Micro PA
Zomig, ZMT QL
Methergine Tabs
Retrovir
Zovirax Oint
Mintezol
Zyprexa, Zydis
Mycobutin
Rifamate
Accolate
Sandimmune Oral
Accupril
Nasonex QL
Sandostatin*
Accuretic
Nebupent
Serevent Diskus QL
Seroquel, XR
Aciphex ST, QL^#
Simcor QL
Actimmune*
Neulasta PA, QL*
Singulair QL
Activella PA
Neupogen PA*
Somavert*
Actiq PA, QL
Nexavar PA
Spiriva QL
Nexium QL
Sprycel PA
Aggrenox QL
Alamast QL^
Nilandron
Strattera
Alferon-N*
Nitro-Bid
Subutex QL
Allegra, D QL^
Nitro-Dur
Sular DO, QL
Alocril QL^
Nitrolingual spray
Alomide QL^
Norpace CR 100mg
Sutent PA
Altace 1.25mg
Altoprev DO
Novolin N, R, 70/30
Symbicort QL
Alupent Inhaler
Synthroid
Alvesco QL
One Touch Product Line QL
Tarceva PA
Ambien QL
Ortho Evra PA
Tegretol, XR
Ambien CR QL, ST
Ortho Tri-Cyclen Lo PA
Tekturna, HCT DO, QL
Amerge QL
OxyContin QL
Amevive PA
Pacerone
Pancrease
Testim PA, QL
Anadrol-50 PA
Thalomid PA
Analpram - HC
Android PA
Plavix QL
Anzemet QL
Plexion SCT
Tobradex
Topamax PA
Aquachloral Supprettes
Pred Mild 0.12%
Transderm-Scop
Aranesp PA*
Arixtra*
Premarin oral, vaginal
Trizivir
Arthrotec ST
Atacand DO, QL
Premphase
Twinject
Atacand HCT DO, QL
Avalide DO, QL
Prenate Elite
Avapro DO, QL
Prevacid QL
Avelox QL
Prevacid Naprapac QL
Avinza QL
VESIcare
Primaquine
Azor DO, QL
Pristiq DO, QL
Beconase AQ ST, QL
ProAir HFA QL
Viracept
Benicar, HCT DO, QL
Betaseron*
Flonase QL
Omeprazole 40mg
Biaxin XL
Floxin Otic
Boniva QL
Foradil QL
Omnaris ST, QL
Bystolic
Fortamet
Caduet DO
Forteo PA, QL*
Omnitrope PA, QL*
Fosamax tablets QL
Capex Shampoo
Fragmin*
Opana ER QL
Optivar QL^
Capozide
Genotropin PA, QL*
Ovidrel PA*
Cardene, SR
Glumetza
Oxandrin PA
Cardizem CD, LA DO, QL
Gonal-f, RFF*
Cardura, XL
Grifulvin V
Panretin
Catapres TTS
Histex, SR
Pantoprozole PA, QL^#
Caverject PA, QL
Humatrope PA, QL*
Pataday QL^
Humira PA, QL*
Patanol QL^
Ceftin QL
Hybolin PA
Patanase QL
Celebrex ST, QL
Infergen* PA
Cetrotide*
Innohep*
Paxil CR DO, QL
Intron A PA*
Pegasys PA*
Cialis PA, QL
Peg-Intron PA*
Cimzia PA, QL
Kadian QL
Penlac PA
Cipro XR QL
Poly-Histine Elixir
Clarinex, D QL^
Kineret PA*
Poly-Pred
Cleocin Vaginal Cream
Kytril QL
Pramosone
Lamisil Spray
Pravigard
Lamisil Tablet PA
Colestid
Lescol, XL DO, QL
Combipatch
Levitra PA, QL
Prilosec 40mg ST, QL^#
Combunox QL
Primaxin QL
Copaxone*
Prinivil
Cordran Tape
Lotensin, HCT
Prinzide
Lotrel (2.5/10, 5/10, 5/20
Procrit PA*
Covera HS DO
& 10/20mg)
Prostin E2 Supp
Crestor DO, QL
Lunesta QL
Protonix ST, QL^#
Lupron Depot PA*
Provigil PA, QL
Cyclophosphamide
Prozac Weekly QL
DDAVP injection
Lyrica PA
Pulmozyme
Delatestryl*
Malarone PA
Raptiva PA
Razadyne, ER
Depo-Estradiol*
Maxair QL
Relenza QL
Depo-Testosterone*
Maxaquin QL
Relpax QL
Methitest
Remicade PA
Dilaudid
Miacalcin Spray QL
Restoril
Dovonex Soln.
Micardis, HCT DO, QL
Revatio PA, QL
Dynacirc, CR
Migranal QL
Requip, XL
Edex PA, QL
Risperdal
Elestat QL^
Rhinocort Aqua ST, QL
Monopril/HCT
Rozerem ST, QL
Emadine QL^
Saizen PA, QL*
Myambutol
Sanctura, XR
Myfortic
Sarafem QL
Enbrel PA, QL*
Mysoline
Seasonale PA
Nasacort AQ ST, QL
Serostim PA, QL*
Estrace vaginal cream
Nasarel QL
Skelaxin
Estrasorb
Neumega PA*
Sonata ST, QL
Estratest, HS
Soriatane
Estrogel
Norditropin PA, QL*
Spectracef
Factive QL
Noroxin QL
Sporanox Solution PA
Norvasc DO, QL
Stadol QL
Fenoglide
Nutropin, AQ PA, QL*
Striant PA
Fentora PA, QL
Nuvaring PA
Suprax QL
First Testosterone
Synagis PA
Synarel PA
Humira PA, QL
Tamiflu QL
Zetia ST, QL
Increlex PA
Zithromax QL
Infergen PA
Tequin QL
Testopel PA
Intron-A PA
Testred PA
Zofran QL
Teveten, HCT DO, QL
Zoladex PA
Kineret PA
Tev-Tropin PA, QL*
Zoloft DO, QL
Leukine PA
Tiazac DO, QL
Zorbtive PA, QL*
Leuprolide PA
Toprol XL
ZyfloTier 4
Toradol QL
Lupron, Depot PA
Treximet
Actimmune
Tri-Nasal
Alferon-N
Methotrexate
Triglide
Metrodin
Trileptal
Aranesp PA
Miacalcin injection
Tussionex
Neulasta PA, QL
Ultram ER QL
Neumega PA
Uniretic
Betaseron
Neupogen PA
Bravelle
Norditropin PA, QL
Urocit-K
Caverject PA, QL
Uroxatral
Cetrotide
Nutropin, AQ PA, QL
Vaseretic
Chorionic Gonadotropin
Omnitrope PA, QL
Colistimeth
Ventolin HFA QL
Coly-Mycin
Pegasys PA
Veramyst ST, QL
Copaxone
Peg-Intron PA
Verelan PM DO, QL
Delatestryl
Delestrogen
Depo Testosterone
Procrit PA
Viagra PA, QL
Depo-Estradiol
Raptiva PA
Vivactil
Voltaren Ophth
Edex PA, QL
Vytorin ST, QL
Eligard PA
Repronex PA
Enbrel PA, QL
Roferon-A PA
Wellbutrin, SR
Epogen PA
Saizen PA, QL
Wellbutrin XL DO, QL
Fertinex
Sandostatin
Winstrol PA
Follistim AQ
Serostim PA, QL
Forteo PA, QL
Somavert
Xolair PA*
TevTropin PA, QL
Xopenex Nebulizer Soln.
Tobramycin
Xyzal PA, QL^
Genotropin PA, QL
Vitamin B12
Yasmin PA
Gonal-f-, RFF
Vivaglobulin PA
Zegerid ST, QL^#
Xolair PA
Zestoretic
Humatrope PA, QL
Zorbtive PA, QL
KEY
# Non-formulary in Indiana only
^ This product has clinically equivalent alternatives included on the formulary and, as a
consequence, such product may not be covered under your pharmacy benefit. Please consult your on-line pharmacy account through your health plan website, anthem.com, for details on coverage.
* = These drugs are Tier 1, 2 or 3 for those members that do not have a Tier 4 plan
PA = PRIOR AuTHORIzATION REquIRED. Prior authorization is the process of obtaining approval of
benefits before certain prescriptions may be filled.
QL = quANTITY LIMITS. Certain prescription drugs have specific quantity limits per prescription or
per month.
ST = STEP THERAPY REquIRED. You may need to use one medication before benefits for the use
of another medication can be authorized. Please note: Foradil and Serevent are safety edits that prevent duplication of therapy.
DO = DOSE OPTIMIzATION REquIRED. Normally involves the conversion from twice-daily dosing to a
once-daily dosing schedule.
Not all medications and not all plans are subject to prior authorization and quantity limits. For more information regarding prior authorization or quantity limits, contact Member Services at the telephone number listed on your identification card.

Source: http://www.pulaskicounty.org/images/Anthem%20prescription%20drug%20list.pdf

Vet-240.p65

Pesq. Vet. Bras. 24(2):57-60, abr./jun. 2004Antimicrobial resistance and R-plasmid in Salmonella sppNorma S. Lázaro2*, Anita Tibana3, Dália P. Rodrigues4, Eliane M.F. Reis4, Bianca R. .- Lázaro N.S., Tibana A., Rodrigues D.P., Reis E.M.F., Quintaes B.R. & Hofer E. 2004. Antimicrobial resistance and R-plasmid in Salmonella spp from swine and abattoirenvironments. Pesquisa Veterinár

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Katrina Howard SC Selborne Chambers, Level 9 174 Phillip Street, Sydney, NSW, Australia Tel: +61 2 9233 5188 Fax: +61 2 9233 1137 Mob: +61 416 230 288 Katrina Howard read and practised at the Melbourne bar, before moving to the Sydney bar in 1993. She was appointed senior counsel in 2006. She was head of Wardell Chambers, level 15, from 2006 until she moved to Selborne

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